Effectiveness of Carbamazepine Versus Oxcarbazepine ....
JKCD December 2015, Vol. 6, No. 1
Original Article
EFFECTIVENESS OF CARBAMAZEPINE VERSUS
OXCARBAZEPINE IN THE MANAGEMENT OF TRIGEMINAL
NEURALGIA
*Hanan Shafiq, *Muhammad Arshad Badar, **Zahur Qayyum, ***Muhammad Saeed
*University Medical & Dental College, Faisalabad, Pakistan
**Woman Medical and Dental College, Abbottabad, Pakistan
***Ex Principal, Nishtar Institute of Dentistry, Multan
ABSTRACT
Objective: To compare the effectiveness of carbamazepine versus oxcarbazepine in the management of
Trigeminal Neuralgia
Material and Methods: This study was conducted over a period of 8 months in 2013, on 202 patients reporting
to the Department of Oral & Maxillofacial Surgery, Nishtar Institute of Dentistry, Multan. New patients of
either gender, age 30-70 years with features of trigeminal neuralgia (TN) with pain intensity of moderate to severe
were included in this study. Patients were divided in two groups. One group was treated with oxcarbazepine and other
group with carbamazepine.
Results: A total of 202 patients, 131 females (64.85 %) and 71 males (35.15 %) were included in this study. The
mean age of these patients was 58.04 ± 7.78 years with an age range of 30-72 years. The relief of pain score in
carbamazepine group was 26 (25.7%) and in oxcarbazepine group was 85(84.2%).There was a significant difference
among both groups (p value=0.00005).
Conclusions: Oxcarbazepine is more effective than carbamazepine in relieve pain intensity.
Key words: Trigeminal Neuralgia, Facial Pain, Carbamazepine, Oxcarbazepine.
INTRODUCTION
orbital foramen, inner canthus of eye, lateral to the ala
nasi and over the mental foramen3. Triggers include
touch, certain head movements, talking, chewing, swallowing, shaving, brushing teeth, or even a cold draft.
The most commonly affected dermatomal zones are
innervated by the second and third branches of the
trigeminal nerve5.
In the primary care setting, diagnosis and initial
treatment of orofacial pain are often performed by
family physicians and dental surgeons1. Trigeminal
neuralgia is a specific disorder diagnosed on clinical
findings, a thorough clinical history and physical
examination. Trigeminal neuralgia is defined by the
International Association for the Study of Pain as “a
sudden, usually unilateral, severe, brief, stabbing, recurrent pain in the distribution of one or more branches
of the fifth cranial nerve”2-4.
Trigeminal neuralgia is an idiopathic disorder.
Occasionally, however, Trigeminal neuralgia constitutes manifestations of central nervous system lesions
(symptomatic trigeminal neuralgia), such as tumors,
cysts, multiple sclerosis (MS) or arteriovenous malformations3,6.
The trigger zone is always ipsilateral to the pain.
Common extra oral trigger zone occur above the supra
There is a lack of certainty regarding the aetiology and pathophysiology of trigeminal neuralgia and
there is a wide range of treatments available7.
Correspondence:
Dr. Muhammad Arshad Badar
Associate Professor & HOD Oral & Maxillofacial Surgery
University Medical & Dental College Faisalabad, Pakistan
Cell: 0333-4080297
Email address: [email protected]
Pharmacological therapy is the first line of treatment in the management of Trigeminal neuralgia. The
32
Effectiveness of Carbamazepine Versus Oxcarbazepine ....
JKCD December 2015, Vol. 6, No. 1
was taken from the patients. Patients were randomly
allocated into two equal groups (group A, group B)
by using the lottery method (202 slips were made with
name, Group A and Group B, each patient were asked
to pick one slip, whatever Group’s name is there on
the slip, that drug was prescribed accordingly).Group
A was treated with oxcarbazepine 200mg BD daily
upto 1200mg. Group B was treated with carbamazepine daily 200mg twice a day upto1800mg. Bias was
controlled by randomly allocating the patients by single
person (researcher). Patients were asked to use visual
analogue scale to score the pain and note the score in
diary. Pain relief was observed after 3 days, 1 month,
and 2 months interval in follow-up. All informations
were collected on a specially designed proforma.
goal of the medical management is the reduction of
neuronal hyper excitability in the peripheral nervous
system, the central nervous system or both3,8.
Anticonvulsants, such as carbamazepine, phenytoin, gabapentin, lamotrigine, oxcarbazepine, and
topiramate are used commonly. These drugs can cause
side effects (e.g. drowsiness, unsteadiness, nausea, skin
rash, blood dyscrasias). Therefore, patients are monitored routinely and undergo blood tests to ensure that
the drug levels remain safe to minimize side effects4. In
patients whose disease is medically refractory because
of sustained, intolerable side effects from medication,
a surgical procedure is considered9.
Surgical procedures that can reduce the frequency and severity of trigeminal neuralgia attacks induce
Peripheral surgery, percutaneous ablative procedures,
stereotactic radio surgery and micro vascular decompression3. Oxcarbazepine, a recently introduced antiepileptic drug, was found to possess antineuralgic properties in neuropathic pain. The dual mode of action
of oxcarbazepine, modulating both voltage-sensitive
sodium channels and high-voltage activated N-type
calcium channels, raises the possibility that oxcarbazepine can target certain underlying mechanisms known
to be important in the genesis of both peripheral and
central sensitization10.
All data was compiled and analyzed using
SPSS-10. Descriptive statistics were calculated for all
variables. Mean and standard deviation was calculated
for all qualitative variables like age of patients, pain intensity. Post medication final pain assessment was done
at the end of two months. Frequency and percentages
were calculated for qualitative variables like gender for
that t- test were applied. Confounding variables like
age, gender were controlled by making stratified cross
matching tables. P-value less than 0.05 was considered
as significant.
METHODS AND MATERIALS
RESULTS
A randomized clinical trial conducted over a
period of 8 months on 202 patients reporting to the
Department of Oral & Maxillofacial Surgery; Nishtar
Institute of Dentistry, Multan with a kn of TN. New
cases in patient of both gender between 31-70% age
were included in this study. Patient already taking any
kind of medication for the treatment of neuralgia,
have underson surgical procedure for management
of Trigeminal Neuralgia had done previously or who
show hypersensitivity to carbamazepine or oxcarbazepine were excluded from this study. Patients with
acute or chronic liver or renal failure and those patients
not willing for follow up were also excluded from the
present study.
Out of total 202 patients with trigeminal neuralgia. A total 131 females were presented in the study
forming 64.85% while 71 males were formed 35.15%.
The mean age of these patients was 58.04 ± 7.78
years with an age range of 35-72 years. Distribution
of age is given in Table-1.
Right side of the face was involved in 127 cases
forming 62.85% while left side was involved in 75 cases
forming 37.15% of all the patients.
The most common division of trigeminal nerve
involved in this study was the mandibular division in
135 cases forming 66.8% of all the patients followed by
maxillary division involved in 62 cases forming 30.7%
of all the patients followed by ophthalmic division
involved in 5 cases forming 2.5% of all the patients.
Ethical issues were considered and managed
during the study after approval from the hospital
ethical committee. After explaining all the benefits
and risks to the patients, written informed consent
33
Among the branches of mandibular division,-
Effectiveness of Carbamazepine Versus Oxcarbazepine ....
mental nerve was involved in 89 (44.05%) cases while
among the branches of maxillary division, infra orbital
nerve was involved in 52 (25.75%) cases. Distribution
is given in Table-2.
The exact cause and the pathology of the trigeminal neuralgia are still controversial. No point is
saved in the trigeminal pathway in which a lesion has
not been described. Mechanical factors like tentorial
ossification12, vascular compression by the superior
cerebellar13, anterior inferior cerebellar and basilar
artery and arteriovenous malformation of the cerebellopontine angle are considered as possible causes.
The mean pain score in carbamazepine group
was 3.42± 0.82 and in oxcarbazepine group was
4.21±0.98.There is a significant difference in the pain
score among both groups (p value=0.00005). Detail
are given in Table-3.
In present study, total of 202 patients presented
with trigeminal neuralgia were treated. The mean age
of these patients were 58.04 ± 7.78 years with an age
range of 35-72 years. Arguelles et al14 conducted a
study on thirty five patients in which he prescribed
oxcarbazepine in trigeminal neuralgia (TN) unresponsive to treatment with the standard antiepileptic
drug carbamazepine for at least 12 weeks. Pain was
assessed using mean pain frequency, responder rate,
pain-free patients and clinical global impression. The
mean maintenance dose was 773.7 mg/day. There was
a significant decrease in the mean of the main scores
following 12 weeks of treatment (p < 0.05) compared
with baseline. Oxcarbazepine was effective from the
first month of treatment. There was a significant reduction in pain frequency, leading to improvements
in patient satisfaction. In general, oxcarbazepine was
well tolerated.
The relief of pain score in carbamazepine
group was 26(25.7%) and in oxcarbazepine group
was 85(84.2%). No relief in carbamazepine group in
75(74.3%) and in oxcarbazepine gropu . no relief was
observed in 16(15.8%).There is a significant difference
among both groups(p value=0.00005).
DISCUSSION
Trigeminal neuralgia is chronic pain syndromes
for its symptomatology and high frequency with which
it responds to anticonvulsant medications, particularly
carbamazepine11.
Table-1: Distribution of the patients according to the age
AGE
(yrs)
Total no.of
cases
Min.
202
35
yrs
Max. Mean
72
yrs
58.04
yrs
Standred
deviation
Solaro et at15 , in one of his study prescribed
oxcarbazepine (dosage 600-1200 mg/day) in 12 multiple sclerosis (MS) patients suffering from painful
paroxysmal symptoms(PPS). The subjective level of
the PPS was scored using a three-point scale (0-3).
The mean dosage of oxcarbazepine was 1033 mg daily.
Nine patients experienced a complete and sustained
recovery within 1 month from treatment initiation (T0
vs. T1, p>0.05)
7.78 yrs
TABLE-2: Distribution of patients according to the
branches
Branch Involved
n
%
Mental nerve
89
44.05
Lingual nerve
8
3.97
Long buccal nerve
7
3.46
Inferior alveolar nerve
31
15.34
Infra orbital nerve
52
25.75
Nasopalatine nerve
4
1.98
Posterior superior alveolar
6
2.95
Supra orbital nerve
3
1.48
2
0.99
202
100
Supra trochlear nerve
Total
In our study, the mean pain score in carbamazepine group was 3.42±0.82 and in oxcarbmazepine
group was 4.21±0.98.There is a significant difference in
the pain score among both groups(p value=0.00005).
Zakrzewska et al16, in one of his study on 29
patients described that a total of 16 (55.2%) females
presented with trigeminal neuralgia while a total of
13 (44.8%) males presented with trigeminal neuralgia.
Warraich17, described in his study that 55 female (61%)
presented with trigeminal neuralgia while 35 male
(39%) presented with trigeminal neuralgia. Sohail et
al18, in his study described 32 (64%) females presented
with trigeminal neuralgia while 18(36%) males present-
Table-3: Difference in pain score between carbamazepine
versus oxcarbazepine.
Mean pain
score
Carbamazepine group
Oxcarbazepine group
p-value
3.42 + 0.82
4.21 + 0.98
0.00005
JKCD December 2015, Vol. 6, No. 1
34
Effectiveness of Carbamazepine Versus Oxcarbazepine ....
ed with trigeminal neuralgia. In our study, 131 (64.9%)
females presented with trigeminal neuralgia while 71
(35.1%) males presented with trigeminal neuralgia. Female formed an overwhelming majority of the patient
population with a percentage of 64.9% in our study.
JKCD December 2015, Vol. 6, No. 1
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